Nowadays, we see in our society people whose sexual behavior have become deviant and unacceptable from societal perspective. This aberrant behavior makes people uncomfortable, who perceive it to be intentional. However in truth, some people who manifest odd sexual behaviour are suffering from a psychiatric illness called Paraphilic Disorder. The most dangerous thing about persons with paraphilic disorder is the involvement of non-consenting human beings or body parts of other person in order to satisfy their urgent and extreme need of sex which creates an enormous risk or actual harm to the surrounding people.

These people may carry out illicit sexual behaviour, committing sexual crimes like rape, sex offending activities, sexual harassment or lust murders in order to gratify their sexual urge. Though it is fairly common, it is very often not recognized as an actual psychiatric disorder, especially in third world countries where people usually have rigid mindsets. Due to its forensic consequences it is very important to understand this disorder and how to deal with these patients.

However, Paraphilia and Paraphilic Disorder are quite different in meaning. According to American Psychiatric Association (2013), paraphilia refers to sexual behavior which is unusual but does not inflict harm to self and others; while Paraphilic Disorder is considered to be the stage when the sexual desire and urges escalates to such an extent that a person cannot concentrate on activities of daily living and which cause serious anguish and functional impairment, and puts others’ safety in jeopardy.

According to McManus (2013), patients suffering from Paraphilic disorder “have a sexual desire or behavior that involves another person‘s psychological distress, injury, or death, or a desire for sexual behaviors involving unwilling persons or persons unable to give legal consent” (p.03). In order to diagnose a person with Paraphilic disorder, the subject must exhibit the above mentioned symptoms and suffer functional impairments for at least 6 months as per DSM-IV-TR (American Psychiatric Association, 2013).

Paraphilic disorder has many subtypes. It is an extensive term which includes different types of paraphilias. According to Thibout, Bara, Gordon, Cosyns, & Bradford (2010), the relatively more common types are:
Exhibitionism: publicity of genital parts to naive strangers.

Frotteurism: in this type the person will touch or rub his body parts against the unwilling person.

Voyeurism: it includes an intense urge to watch and observe a person who is bare or engage in sexual activity. This type is more often observed in males.

Fetishism: in this type of paraphilia, the person may satisfy his sexual urge by nonliving objects like undergarments, clothes, handkerchief, shoes etc. this is also more common in male gender.

Necrophilia: in this type of paraphilia the person derives sexual satisfaction from eating, touching, rubbing, smelling, watching the genitals of dead body and also by performing sexual intercourse with it.

Sexual masochism: a person with this type of paraphilia may enjoy being beaten up, or being humiliated or getting injured. This type may involve self-inflicted harm.

Sexual sadism: this is the most extreme and antisocial type of paraphilia. In this case the person will cause sexual harm to others especially to those who are unwilling. The person who is diagnosed with this type will find it thrilling to cause emotional and bodily harm to others.

Pedophilia: this is a type of paraphilia in which the person satisfies his sexual urge from a victim of pre-pubertal age.

According to Dawn Newspaper (2015), in Pakistan the most common types of paraphilia found are frotteurism and pedophilia. A number of cases are reported (and many go unreported) each year of child molestation, child rape, child sexual offenses and child sexual exploitation. The most recent evidence of pedophilia in Pakistan is the Kasur incident, in which more than 200 children became victims of sexual exploitation and child molestation (The Express Tribune News, 2015)

Moreover, as far as prevalence of frotteurism is concerned, it has been seen especially in shopping malls and overcrowded places many men take it as an opportunity to touch or rub their private parts inappropriately against strangers. It is reckoned to be very common in Pakistan but no cases have been reported at present. A few years back, an incident of necrophilia occurred in Pakistan. The incident regarded a person who reportedly dug out dead bodies from graveyards and attempted sexual intercourse with recently buried bodies (The Express Tribune Newspaper, 2011).

These incidents draw attention to the fact that paraphilia exists in Pakistan to a large extent. However it is difficult to distinguish between those who have a real psychiatric disorder and those who are doing it intentionally just to harm others or to take revenge. In addition to this it is also hard to diagnose a person who exhibits odd sexual behavior with a psychiatric disorder in our country, where people feel immense hesitation in consulting a psychiatrist or psychologist. So as far as evidence is concerned regarding prevalence of Paraphilic Disorder, there are no official records available because people most often choose not to disclose such deviant sexual behavior to psychiatrist.

Social perspectives about paraphilic behavior:

The behavior that paraphilic patients may exhibit are considered to be odd, bizarre and a harmful activity by the society. Those unusual sexual activities includes rubbing of genitalia publicly, touching unwilling person inappropriately, watching and creating pornography, and forcing children or under age person to involve in sexual activity etc. All of these behaviors are extremely unacceptable in any respectable society; they go against social norms, morals and values. Furthermore, it has been seen that paraphilia is largely found in males (Marsh, 2010). (p.133), as compared to females and in patriarchal third world countries women are more likely to be victimized by paraphilic patients who see them as more vunerable. Another challenge regarding paraphilia in many third world countries is that literacy levels are very low which creates hindrance in accepting such behavior to be a part of a psychiatric disorder.

Ethical and legal issues related to paraphilic patient:

According to Hamilton (2013), it has been seen that most patients of Paraphilic Disorder are involved in illegal sexual activities like rape, sexual harassments, sexual offences, child molestations, pornography etc. which are objectionable by law. There exists a huge dilemma regarding whether the person who has committed rape deserves to be incarcerated, so that justice can be given to victim or should he/she be acquitted just because of his psychiatric disorder? In some countries such patients become incarcerated as per their respective punishment duration but it has also been seen that people with this disorder have committed sexual offenses again and again after getting released from the prison. If we consider person blameless for such sexually offensive behavior then it would become very problematic to offer justice and to maintain law enforcement. Furthermore distinguishing between the actual patient and the actual abuser will also become a challenging if not impossible task.

Treatment in terms of psychotherapy and pharmacotherapy:

Pharmacotherapy:

Anti-androgen drug Depo-vera can be administered to decrease the sexual urge of the patient who is diagnosed with Paraphilic disorder. The distress and functional impairment of the patient would be directly reduced by decreasing sexual urge. The medications used are anti-depressant and anti-psychotic drugs which helps the patient in gaining a control over him or herself. Moreover in many prisons of the world, paraphilic patients who are incarcerated because of their sexual offences are mostly getting the same treatment. However not all of these patients need medication; it all depends on the severity of their individual case. (Berlin, 2009). (p.236).

Psychotherapy:

The majority of paraphilic patients does not agree to undergo psychotherapy for their treatment. However there are a numbers of psychotherapies available for these patients, like confrontational therapy in order to make them realize the effects of their action on others; traditional psychotherapy or group therapy can benefit these patients in terms of gaining awareness of their abnormal sexual behaviours; and cognitive behavioral therapy which employs preventive strategies like mind diversion, moving away from stimuli etc. is also used to avoid relapse. And these patients need lifelong monitoring in which surveillance systems can play a major role.

Good Lives Model therapy is also considered very effective nowadays and psychotherapists support this therapy. In this therapy the patient learn those skills which are required to have in order to understand the natural and socially acceptable sexual behaviors (Yakeley & Wood, 2014). According to Thibaut et, al. (2010), paraphilia is usually a chronic condition and hence its prognosis is very poor.

Recommendations:

Dealing with a paraphilic patient:

As a responsible member of society:

* As a paraphilic patient becomes stimulated by the victim’s expression of anxiety, tremor, and hatred (including verbal and physical), it is better to remain quiet at that moment and immediately report the whole incident.

* Always stay quiet and avoid challenging them it may increase their intensity of sexual urge as well as their sexual frustration.

* Surveillance system in psychotherapy plays a very important part. It is also very essential responsibility of family members or the guardian to watch over the patient’s behavior and at time of need take them to their family psychotherapist.

* Family and in school sex education should be given at an appropriate age so a person can recognize his/her sexual orientation early. It will also prevent others by making them aware of inappropriate sexual activities in order to report on time if any incident ever happens with them.

As a psychiatric nurse:

* A nurse should assess the client for all the co-morbidity, risk factors, stimulating factors which can be prove harmful to his/her psychiatric illness.

* A nurse should encourage the client to express his or her feelings regarding his psychiatric illness. Through enough ventilation of feeling there will be less building up of frustration.

* A nurse should be careful in terms of developing transference when dealing with such patient because paraphilic patients can develop it very easily.

* A nurse should encourage the client to comply with psychotherapy as well as pharmacotherapy and nurse should also confront the client that by maintaining compliance not only he would suffer but also the people who surround him/her will also suffer because of his deviated sexual behaviours.

* A nurse should inform the client prior to therapy, which circumstances confidentiality may be breeched along with the rationale.

* A nurse should work along with family in order to make them understand how they should behave with such a patient. The nurse should also verbalize the importance of constant monitoring of the paraphilic’s behaviour.

Conclusion

From the above account it is very much clear that living with people who are suffering from such psychiatric disorder is very difficult. Not only living with, but also understanding their disease process and also accepting them as an equal and respectable member of a society is quite a big challenge. However it is an emergent need to accept them as Paraphilic patient so that they are not discouraged from looking for a treatment. We all know very well that Paraphilic disorder is very much prevalent in our society and it has terrifying consequences for other members of society like rape, sexual harassment, child molestation etc. Now this is the time to recognize them as psychiatric patient and encourage them to get treated in order to ensure the welfare and safety of the society as a whole.

About the Author: Heena Akber Ali is a BScN student at Aga Khan University, Pakistan. She is a two year scholarship holder and very inquisitive regarding medical research as well as promoting the importance of psychosexual health of a person. Her research regarding tender coconut water as a temporary substitute for blood plasma in emergency was published and presented in the 8th Health Sciences Research Assembly of Aga Khan University. Heena is also very inclined to start her own social business for which she attended the National University of Singapore entrepreneurship program, Singapore, in July 2015. She can be reached at [email protected]

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